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Division 42, APA Practice Information Clearinghouse of Knowledge

I. Niche Practice Specialty: a) Title/Identification of niche Working With AD/HD Children and Their Parents

b) Author Steven Sussman, Ph.D. Founder, Child & Teen Success Centers of NY & NJ, 339A Harold Street, Staten Island, N.Y. 10314 718-982-0262

c) Professional Affiliations APA-Divisions 42 & 46

II. Introduction: a) Brief background, history, and theory of the niche and technique. Childhood psychological disorders were little researched and understood for most of this century. Gross, poorly defined diagnostic categories existed for childhood neurosis, psychosis, autism, and hyperkinesis. Hyperkinesis, excessive motor activity, was the original name for hyperactivity. Hyperkinesis was also referred to as Minimal Brain Dysfunction (MBD) because it was thought to be caused by undetectable brain damage. In 1980, DSM III came out clarifying the role of inattention in the disorder. Today, the DSM-IV calls the symptom complex of inattention, impulsivity, and excessive motor activity as AD/HDs (Attention Deficit/Hyperactivity Disorders, Inattentive type, Impulsive-Hyperactive type and Combined type). According to the DSM-IV, if a client has six or more of nine specified inattentional symptoms e.g., being easily distracted, trouble finishing simple chores, tendency to lose things, etc., he is the Inattentive type. If the client has six or more of nine impulsive/hyperactive symptoms e.g., blurting out answers in class, inability to stay in his seat, or restless, squirmy movements, etc. he is the Impulsive-Hyperactive type. If the client has both sets of symptoms, he is the Combined type. It is common for the media, general public, and research community to use the term Attention Deficit Disorders or ADDs to include all of the three subtypes. For the purpose of this paper, the DSM IV nomenclature of AD/HDs will be used. The National Institute of Health has done brain-imaging studies that show clear differences between the brain activities of AD/HD and non-AD/HD subjects. This research plus thousands of other studies has established AD/HD as a true biopsychological disorder. The advocacy of consumer groups, such as CHAAD (Children & Adults With ADD), has resulted in the increased public awareness of AD/HD and the passage of advocacy legislation. This has culminated in Federal Education Law 504, under the Americans With Disabilities Act. This law requires all school districts to provide assessment and supplemental services to children classified as having disabilities including neurological/cognitive impairments, such as AD/HD. Insurance companies are being forced to recognize AD/HD as a bio-psychological disorder that requires ongoing treatment(s). These disorders occur uniformly across socioeconomic classes and are estimated to affect anywhere from 2-10% of the population. Males are affected roughly 3-5 times as frequently as females.

III. Method: a) Intervention The psychologist who works in this area is called upon to diagnose the presence and type of AD/HD (Combined type is the most common, followed by Inattentive and Hyperactive types, respectively) as well as any co-existing psychological conditions. Disruptive behavioral disorders, learning disabilities, and/or social/developmental disorders, more often than not, co-exist with AD/HDs. The psychologist often initiates and oversees a multi-disciplinary approach that includes behavior modification, cognitive-behavioral training, academic support and tutoring, and medication evaluation. Ritalin, a stimulant, is by far the most frequently prescribed medication for AD/HD. Stimulants are believed to work by increasing the activity level of the brain's control centers in people with AD/HD, leading to increased attention and self control. This has been referred to as the "paradoxical effect" because a stimulant makes AD/HD clients more focused and, hence, calmer rather than more aroused. Psychological treatment will almost always focus on skill remediation. By DSM-IV specifications, AD/HD diagnoses require demonstrable impairment in more than one setting, i.e., school and home, work and play, etc. Therefore, a psychologist must be able to help clients who are having difficulties on a daily basis in different settings. Sophisticated diagnostic skills are critical because of the prevalence of clients with co-existing disorders, which require consideration in treatment planning and implementation.

b) Technique Outline Initial Evaluation- Upon a request for services, a psychodevelopmental questionnaire and a set of various child rating scales are completed by the child client's parent(s) or caregiver(s). The questionnaire elicits developmental, emotional, social, medical, genetic, and academic background. A Conners' Parent Rating Scale-Revised (1996), filled out by primary caregiver, can compare the child to a national sample of peers in terms of the following problems- Cognitive/Inattention, Conduct, Learning , and Global (overall severity). An ADD-H Comprehensive Teacher's Rating Scale (1991) by Ullmann et. al. can be given to the child's main teacher(s). This compares the child to his peers in the following school behaviors-Attention, Hyperactivity, Oppositionalism, and Social Skills. An Australian Scale For Asperger's Disorder (1998) by T. Attwood can be used to provide an index of social/developmental problems. A DSM-IV symptom checklist for Oppositional Defiant Disorder and Conduct Disorder is often used to reveal the presence of any co-existing Disruptive Behavioral Disorders. These rating scales and the developmental history are then evaluated in the context of school report cards and any previous psychoeducational testing. Thorough interviews are then done with the parent(s) and child to gain additional information or impressions. An initial diagnostic impression is formulated with delineation of skill deficits. A treatment plan is devised that emphasizes skill training, unless more serious mental illness or environmental factors take precedence. If any diagnostic questions remain after the intake process, further evaluation may entail psychoeducational testing. The Wechsler Intelligence Scale For Children-Third Edition (WISC-III), and Wechsler Individual Achievement Test (WIAT) or some other academic achievement test may be given to clarify IQ and detect learning disabilities. In very complex cases, or ones that are particularly resistive to past treatment(s), a comprehensive personality measure may be needed such as the Personality Inventory For Children (PIC) or the Minnesota Multiphasic Personality Inventory-Adolescent Version. These instruments give a robust picture of the child's or adolescent's functioning. Projectives can be given, if psychodynamic issues appear to be prominent. Wherever indicated, a consultation referral is made to other professionals such as a neuropsychologist, pediatric neurologist, developmental pediatrician, child and adolescent psychiatrist, or a physical/occupational therapist. Treatment Program-Children and adolescents with AD/HD do not benefit adequately from insight oriented psychotherapy because their cognitive deficits and behavioral symptoms often impair their ability to delay action and introspect. Many of these clients need help with understanding cause and effect. Behavior modification techniques like response cost that use immediate consequences can be helpful, especially with younger, hyperactive children. Behavioral contracting is better for older clients. Cognitive-behavioral strategies such as reframing, solution generation, and visualization are suitable for most clients. AD/HD children and adolescents can benefit greatly from cognitive-behavioral group therapy. Groups provide for the live demonstration and supervised rehearsal of interpersonal skills and problem solving approaches. Groups also offer friendship, support, and validation. Therefore, clients are best treated in group therapy with peers who are similar in age and developmental level. Groups are ideally made up of 6-8 clients and are 60-75 minutes in duration. Self-control techniques, like anger management and relaxation, are practiced. Social skills, such as cooperation, sharing, and conflict resolution, are taught. All of the above techniques can be taught using a quiz show format. Successful responses are prompted and shaped by the reward of points for the execution or articulation of adaptive or correct responses. Points are deducted for violations of group rules, social norms, and inattention. Points are tallied and age- appropriate prizes are selected by the clients in order of point totals. The group therapist(s) should be enthusiastic and can use humor, props or sound effects to enhance reinforcement. AD/HD adolescents need more conventional therapy groups that teach assertiveness and decision making and focus on peer pressure, identity formation and sex and substance counseling. The parent(s) of all clients should be involved in the treatment. Our center urges all parents to attend a bi-weekly group therapy that teaches more effective patterns of reacting to the skill deficits and behavioral problems of their children. Quite often, these families have maladaptive ways of handling their children's symptoms and need to learn how to develop proactive strategies and consistent discipline techniques.

IV. Discussion And Evaluation: a) Relevant Research Currently, there are two major theoretical viewpoints emerging. The Disinhibition theory is advanced by Russell A. Barkley, PhD who is the most well known researcher in AD/HD. He posits AD/HD to be an impairment in the brain's ability to inhibit impulsivity. Hence, the AD/HD child appears inattentive or hyperactive because he cannot inhibit himself. If Barkley's position gains prominence, the disorder may be renamed Disinhibition Disorder. Thomas Brown, PhD of Yale University is one of the main proponents of viewing AD/HD as a disorder of Executive Functions. In his view, the brain's higher order activities, like organizing and planning, are impaired resulting in the clinical symptoms of inattention and hyperactivity.

b) Boundary Conditions Many parents are fearful of having their children classified as AD/HD by their school districts. They worry that this "label" will follow their children through school and hurt their chances to get into a college. Since, effective treatment often necessitates school involvement, this fear may need to be resolved. The reluctance on the part of the parent(s) is often overcome when it is pointed out that a proper diagnosis requires teacher input. In addition, if Ritalin is prescribed, the school nurse needs to be aware of this and may need to give an afternoon dose. Also, the teacher is usually the best source of evaluating the effectiveness of any behavioral or medical treatment. This is because they can compare the child's attention/hyperactivity levels with those of his peers, before and after treatment. Some parents worry that the child's self esteem will suffer, if the child is informed of his diagnosis. In fact, AD/HD children usually benefit from this knowledge, as it empowers them to understand and remedy their difficulties. Finally, psychoeducation for the entire family is recommended.